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DOTHAN COSMETIC DENTISTRY

Dr. Geoff Gaunt, D.M.D



Patient registration

  • Chart Id:
  • Date:
  • First Name:
  • Last Name:
  • Middle Initial:
  • Address:
  • City
  • State
  • Zip
  • Home Phone:
  • Sex:
  • Male Female
  • Cell Phone:
  • Dob:
  • Age:
  • Work Phone:
  • SSN:
  • Email:
  • Driver Lic:
  • Marital Status:
  • Single Married Widowed Separated Divorced
  • Employment Status:
  • FULL TIME PART TIME RETIRED
  • Prefered Dentist:
  • Student Status:
  • FULLTIME PART TIME
  • Prefered Pharmacy:

RESPONSIBLE PARTY (IF SOMEONE OTHER THAN PATIENT)

  • First Name:
  • Last Name:
  • Middle Initial:
  • Address:
  • City
  • State
  • Zip
  • Home Phone:
  • Primary Insurance Holder:
  • Cell Phone:
  • Dob:
  • Age:
  • Work Phone:
  • SSN:
  • Email:
  • Driver Lic:
 

INSURANCE INFORMATION

  • Primary:
  • Secondary:
  • Name Of Insured:
  • Name Of Insured:
  • Relationship:
  • Dob:
  • Relationship:
  • Dob:
  • Insured SSN:
  • Insured SSN:
  • Insurance:
  • Insurance:
  • Policy Number:
  • Policy Number:
  • Address:
  • Address:
  • City:
  • State
  • Zip:
  • City:
  • State
  • Zip:

 

DOTHAN COSMETIC DENTISTRY

Dr. Geoff Gaunt, D.M.D


Medical History

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Healthproblems that you may have, or medication that you make be taking, could have an important interrelationship with the dentistry you will receive. Please answer the following questions so that we may treat you to the best of our ability. Thank you!

  • Are you under a physician's care now?
  • Yes No
  • If yes
  • Have you ever been hospitalized or had a major operation?
  • Yes No
  • If yes
  • Have you ever had a serious head or neck injury?
  • Yes No
  • If yes
  • Are you taking any medication, pills, or drugs?
  • Yes No
  • If yes
  • Do you take, or have you taken, Phen-Fex or Redux?
  • Yes No
  • If yes
  • Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
  • Yes No
  • If yes
  • Are you on a special diet?
  • Yes No
  • If yes
  • Do you use tobacco?
  • Yes No
  • If yes
  • Do you use controlled substances?
  • Yes No
  • If yes
  • Women: Are you...
  • Nursing? Pregnant/Trying to get pregnant? Taking oral contraceptives?
  • Are you allergic to any of the following?
  • Acrylic Aspirin Codeine Latex Metal Penicillin Sulfa Drugs Local Anesthetics
  • Other:
  • Do you have, or have you had, any of the following?
  • AIDS/HIV Positive
    Alzheimer's Disease
    Anaphylaxis
    Anemia
    Angina
    Arthritis/Gout
    Artificial Heart Valve
    Artificial Joint
    Asthma
    Blood Disease
    Blood Transfusion
    Breathing Problems
    Bruise Easily
    Cancer
    Chemotherapy
    Chest Pains
    Cold Sores/Fever Blisters
    Congenital Heart Disorder
    Convulsions
  • Cortisone Medicine
    Diabetes
    Drug Addiction
    Easily Winded
    Emphysema
    Epilepsy or Seizures
    Excessive Bleeding
    Excessive Thirst
    Fainting Spells/Dizziness
    Frequent Cough
    Frequent Diarrhea
    Frequent Headaches
    Genital Herpes
    Glaucoma
    Hay Fever
    Heart Attack/Failure
    Heart Murmur
    Heart Pacemaker
    Heart Trouble/Disease
  • Hemophilia
    Hepatitis A
    Hepatitis B or C
    Herpes
    High Blood Pressure
    High Cholesterol
    Hives or Rash
    Hypoglycemia
    Irregular Heartbeat
    Kidney Problems
    Leukemia
    Liver Disease
    Low Blood Pressure
    Lung Disease
    Mitral valve Prolapse
    Osteoporosis
    Pain in Jaw Joints
    Parathyroid Disease
    Psychiatric Care
  • Radiation Treatments
    Recent Weight loss
    Renal Dialysis
    Rheumatic Fever
    Rheumatism
    Scarlet Fever
    Shingles
    Sickle Cell Disease
    Sinus Trouble
    Spina Bifida
    Stomach/Intestinal Disease
    Stroke
    Swelling of Limbs
    Thyroid Disease
    Tonsillitis
    Tuberculosis
    Tumors or Growths
    Ulcers
    venereal Disease
    Yellow Jaundice
  • Have you ever had any serious illness not listed above?
  • If yes
  • Comments:
  • To the best of my knowledge, the questions on this form have been correctly answered. I understand that providing incorrect information can be dangerous to my (or the patients) health. It is my responsibility to inform the dental office of any changes in my medical status.
  • Date

DOTHAN COSMETIC DENTISTRY

Dr. Geoff Gaunt, D.M.D


Questionnaire

  • Patient Name:
  • Date:

Please take the time to answer the following questions for us. This will help us to better understand and address each of your unique concerns.

  • 1. Where you referred to our office?
  • Yes No
  • 2. If so, who may we thank for your referral?
  • 3. When was your last professional cleaning and bywhom?
    • a. Where there X-Rays taken at that time?
    • Yes No
  • 4. How often do you have your teeth cleaned?
  • 5. How often do you floss your teeth?
  • 6. Do you have sensitive teeth?
  • Yes No
  • 7. Do you have a history of gum disease?
  • Yes No
    • a. If so, have you seen a specialist?
    • Yes No
  • 8. How do you feel about dental visits?
  • RELAXED ANXIOUS NEUTURAL
  • 9. Tell us about your habits. Do you....?
    • a. Grind or Clench?
    • Yes No
    • b. Bite your fingernails?
    • Yes No
    • c. Smoke?
    • Yes No
    • If yes, how many per day?
    • d. Use smokeless tobacco?
    • Yes No
    • e. Use a hard toothbrush?
    • Yes No
  • 10. Do you or your partner snore?
  • YOU YOUR PARTNER BOTH
  • 11. Do you feel tired during the day?
  • Yes No
  • 12. Does your bite feel right?
  • Yes No
    • a. If no, please explain
  • 13. Do you wake up with headaches?
  • Yes No
  • 14. Do your jaw joints hurt?
  • Yes No
  • 15. Have you had Orthodontics (braces)?
  • Yes No
    • a. If so, who did them and when were they removed?
  • 16. Do you like the appearance of your teeth?
  • Yes No
  • 17. What about the appearance of your teeth bothers you?
  • Stains Chips or cracks Unattractive: Crowns or Bonding
    Color Length White or dark spots
    Spaces Crooked teeth Shape of teeth
  • 18. Would you like your smile to look 10 years younger?
  • Yes No
  • 19. Are you concerned about a receding gumline?
  • Yes No
  • 20. Do you want to have any missing teeth replaced?
  • Yes No
  • 21. Do you have any silver fillings that you would like to have replaced with new white bonded fillings?
  • Yes No
  • 22. Do you have teeth that you believe need porcelain veneers or all-porcelain crowns?
  • Yes No
  • 23. Would you like to learn more about invisible braces?
  • Yes No
  • Please Tell Us more about your dental goals:

DOTHAN COSMETIC DENTISTRY

Dr. Geoff Gaunt, D.M.D


Acknowledgement of receipt
of notice of privacy practices

  • Date

I, , have received a copy of Dothan Cosmetic Dentistry NOTICE OF PRIVACY PRACTICES. I acknowledge thatI understand the use of my private information for treatment and insurance purposes.I give my consent for Dothan Cosmetic Dentistry to file my information for me

  • Patient Signature:
  • Witness Signature:

DOTHAN COSMETIC DENTISTRY

Dr. Geoff Gaunt, D.M.D


Statement Of Financial Responsibility

Assignment of Insurance Benefits I hereby authorize payment directly to Dothan Cosmetic Dentistryof all medical benefits otherwise payable to me or on my behalf for the treatment(s) performed and/or service(s) rendered at Dothan Cosmetic Dentistry. I understand any payment sent directly to me shall then be forwarded to Dothan Cosmetic Dentistry. I understand any unpaid deductibles, co-pays, or co-insurance amounts not payable by my insurance are my responsibility regardless of any pending insurance amounts. These amounts due from me are due on the date of service. This assignment of benefits is valid for insurance companies and programs.

Authorization of Release of Information I authorize Dothan Cosmetic Dentistryto release any and all medical information concerning the treatment(s) and/or service(s) performed at Dothan Cosmetic Dentistryas may be required by my insurance company in order to process payment of my claim(s)

Charges I understand that standard charges have been established for all services at Dothan Cosmetic Dentistry. I further understand that the fee(s) for my treatment(s) and/or service(s) performed at Dothan Cosmetic Dentistrywill be billed to my insurance company. If any additional treatment(s) and/or service(s) are deemed necessary by my physician, and performed today, those treatment(s) and/or service(s) will be billed to my insurance company as well.

Credit Policy Dothan Cosmetic Dentistrywill file the appropriate claim forms to my insurance carrier. I will be notified when the final action (payment, denial, etc.) by my insurance carrier has been received. I understand that if myaccount becomes delinquent it will be placed with Prim and Mendheim LLC. Further, I agree to the following terms regarding any outstanding balance that I owe: (1) I will incur interest at the rate of 1&1/2 percent per month (18% per annum); (2) I agree and hereby consent that I will be responsible for reasonable collection costs, attorney's fees, and any court costs that are incurred by Dothan Cosmetic Dentistryin the collection of same, whether such outstanding balance is satisfied prior to, after initiation of a lawsuit, or after a judgment has been issued in a lawsuit; and (3) I agree and hereby consent that any lawsuit and/or legal proceeding surrounding the outstanding balance and debt, and fees and costs thereon, shall be initiated and litigated in the court of appropriate jurisdiction of Houston County, Alabama, and I hereby waive any and all defenses and/or objections to said jurisdiction. I agree that if I have listed a cell phone number as a point of contact that I can be called at that number regarding my balance. Additionally, I agree to waive any and all state and/or federal personal property exemptions, wage exemptions, and/or homestead exemptions of my state of residence and/or state of operation in the event of judgment, levy, and/or garnishment. Further, if I reside in Floridaor GeorgiaI agree to waive my rights to any exemption that would prohibit a wage garnishment should same become necessary to secure payment of any outstanding balance.

I, , have read and understand the terms of this policy statement.

  • Date
  • Patient's Signature (Parent or Guardian if Minor)
  • Date
  • Signature of Insured if other than Patient


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